Will this be on the test?

I find myself giving test-taking tips at every tutoring session lately.

Five tips for taking tests in nursing school: *

• Read the question.

Seriously, read it. Stop, don't look down at the answers yet. Read the question once more, looking for these words or phrases: LEAST LIKELY, MOST LIKELY, PRIORITY INTERVENTION, NOT, FIRST. Underline them when you find them. You absolutely must know what the question is asking before you attempt to answer it. If the question makes you think of that awesome little song that you made up to remember the cranial nerves, go ahead and jot them down out to the side right quick BEFORE you look at the answers.

• Think of the patient.
  

When you study, think of how this will look in an actual patient. If I was in the room with someone who had a Foley cath in, what is the very first thing that I need to think about before that patient ambulates? My list of ALL the things to consider before they start traipsing about would include: where's the bag and who's going to hold it, when's the last time this person got up and should we sit and dangle first, are there any obstacles in the intended path and who will move them, and what other lines do we need to pay attention to (like IV poles, or wound drains, or whatnot). Now prioritize them. What must happen first? What can wait? What means Something Bad and what is an Expected Outcome?
Of those, I think that passing out onto the cold dirty hard floor of orthostatic hypotension has to top the list of Things to Pay Attention To. Having one's foley pulled out with balloon still inflated would be right up there as a very close second.

• ABC, 123.

When prioritizing interventions, as above, or in questions where you are asked to assess a patient and choose the most worrisome data, start as low on Maslow's pyramid as possible.
Airway Breathing Circulation
1 heart, 2 lungs, oriented x3 (who are you, where are you, when is it)
Risk for Powerlessness is always going to appear on my list of Relevant Nursing Diagnoses for any hospitalized patient. Always. Let's face it, laying in bed with no underwear does not increase one's self-efficacy. But I cannot assess anyone's psychosocial needs or even their pain level (which is usually next on my list after the ABCs and 123s) if they are currently not breathing or bleeding out.

• Do another med check.

Patient safety has got to be right up there at the top of the priority list. You have to do three med checks, but four can't hurt, especially if you're in a skills evaluation and you simply can't remember doing that 2nd one before you left the Pyxis. "Put on gloves" is always a good idea, along with "Wash hands and document". The phrase - siderails up times two bed low and locked call bell in reach - is burned into my brain forever. This stuff will find its way onto the written exams, too, so be on the look-out.

• "Call the doctor" is almost never the answer.

It seems like a good idea, I know. Interdisciplinary blah-blah-blah? They're going to have to write the orders? I know. But resist, for just a second.
Think about this - What are you going to say when she returns your page? Stammer, stammer, the patient uh, is, uh, doesn't look right and I think you should come down here. Click.
Assess before paging anyone - unless it's a code that you think you should call, and then holler away! Think through the information that a consultant is likely to ask you if you paged them - axillary temp, blood pressures for the last ten minutes, hematocrit levels, intake and output totals for the last 12 hours? What is the thing that made you worry about this patient and what information do you need to gather about that worrisome sign or symptom? Get it all written down, and then call (abcd - assess before calling doc).

*of course, I only know about MY nursing school. I know that all nursing students do skills evals, but I don't know if you will be able to talk to yourself throughout yours the way we were encouraged to do. I think these are pretty universal, and not just based on my Fundamentals professor. of course, your mileage may vary.

Mama Drama

I have a story.

At the beginning of the semester, I sent a note to the course coordinator, saying that my son's birth was traumatic, and that I was a bit nervous going into the setting again, although it had been several years. She said nervous is normal, and maybe I should let the clinical instructor know how I was feeling. Done, with conversation from course coordinator attached for history and context. I ended the email with this:

I feel confident that I can handle this course and I don't want kid-glove treatment at all! I just wanted you to know that I have really strong feelings about this stuff (in other words, I will cry during clinical at some point this semester!)

No response from clinical instructor, which was fine with me. It was perhaps too informal, I'll admit. But I did just come off Psych, and we all know how it went when I cried in front of that professor.

We've been meeting each Monday since the beginning of January with no mention of any of this, other than an aside on the first pre-conference that she knew I had a child, and who else has kids?
Last Monday, I saw TWO births (amazing, incredible and I'll write them up soon, I promise!). I also was talking about my son's birth briefly with two other students in the break room while we ate, and the CI was in the room. She said, "Oh you did have a traumatic birth." I used to enjoy the shock value a little, but I normally don't talk about it anymore - honestly, people are uncomfortable when they realize the implications of the vaginal delivery of an 11 pound, 11 ounce baby and subsequent fourth degree tear. Even indirectly, one's own rectum is not an easy thing to discuss socially, I've found.

The CI and I left together that evening, and she brought it up again. She said that she wasn't sure how to respond and so just played it by ear. I told her that's exactly what I had hoped that she would do, honestly, that I wanted her to know so that she could be prepared, but not because I thought that she would need to intervene in any way. She said, in her Midwestern drawl, "You know, it's been how long, seven years? If you're still having these strong feelings, you ought to think about getting counseling". I smiled uncomfortably and waited until she stopped talking and I could get away. Again? Really? Am I the world's craziest student?

got an email from her two days later that began and ended this waywith this sentence:

Although your clinical performance has been very good, I think you should seek counseling your issues related to your childbirth 7-8 years ago...

Your unresolved long standing issues impede your ability to learn as a student and grow. Please give this matter some serious thought.

See you next week.

So.

There's that, then.

I've stopped screeching phrases like "how would she know?!" and "impede my ability to grow and learn as a student?!" incredulously. I have stopped obsessing about what I would do if she brings it up again as justification for a poor evaluation. While counseling is in order for me (as it is for most humans who have ever experienced anything), it's not on the wait-list for things to do this semester or even this year, I think. Also, I didn't fucking ask you. I guess since I brought it up in writing, she was obligated to respond in writing. but jesus. This is so intrusive, so cold and clinical.

I was all ready to fire off an email detailing my emotional reaction to her note. My friend said, No! She is asking you not to cry on her! Don't cry on her again! Mom said the same. I am immensely grateful for their translation. One of the things that disturbed me so much was that I was attempting to avoid this sort of interaction by sending the email in the first place. I was trying to construct some distance and professional detachment around an issue that is still tender for me, but I did it in a way that put my guts out there to begin with. In a way, it seems that I invited this intrusion into my emotional state; not literally, but on a sort of cosmic plane. What was I hoping to avoid in the first place here? Would I benefit from spending some time on this? Perhaps not with a counselor, but in meditation, doing some root chakra energy work, focused journalling?

I am practicing my pleasant, competent, yet emotionally detached personna for clinical conferences. I am wondering what this means about my way of being in the world in general and as a student in particular. And I'm thinking of it in terms of the conversation that Loving Pecola and darkdaughta are having about what can be expected from the world of academia.

Tonight went well, but I did give in to the temptation to tell a short form of this story to another student who got a similar nasty-gram. I regretted it immediately - it was purely for one-upping the other student, not because she and I are close or she needed my support. I even wonder about posting it here - but will leave it for now.

The instructor did add a comment at the bottom of my clinical journal entry from last week about the births: "I think this week was therapeutic for you!"

More than you know.

There's no crying in Skills Lab!

I had my first tearful scene in a lab today. I was trying (and repeatedly failing) to draw normal saline into a tuberculin syringe with a vanishing needle. The needle doesn't actually vanish, it just pops into the body of the syringe when you push the stopper hard enough. Twice, I pushed it hard enough while I was only trying to push the saline back into the vial to remove a stubborn air bubble. The overall goal of this portion of the lab was to get 1mL of saline into a nice intradermal wheal on a hot dog. The voice in my head said - Jesus, you can't even pull 1mL of saline to inject a hot dog! How can you even think about being able to make it through this program?! And I dropped my second syringe on the tray and stumbled for the bathroom.
Please understand that although I grew up in the American South, I never have been graceful about crying. My nose gets bulbous and red, my sclera is bright red instantly, and within seconds, my whole face is covered in pink splotches of embarrassment/anger/fear. It makes me even more upset, because if i glance at someone and they know that I've been crying (and HOW could they NOT!) and they react with anything approaching pity, I know it's over and I'll full-out sob. I don't know why I've got such a strong denial instinct for crying, but it seems that even after thirty some years of experiences in which I cannot stop myself from crying, I still try.
Deep breaths in the bathroom stall. Positive self-talk. Frantically try to think of a song that will calm me. I try each of these interventions for about 18 milliseconds and am shocked that none of them work very well. I wash my hands, am shocked at the way my face swelled up like Hitch's after eating some shellfish, and square my shoulders to go back to lab.
After properly disposing of the last syringe, and noting that even in emotional crisis, one should always stop off at the sharps containers, I get a new syringe and keep my head down so that no one looks at my face.
Pa-pow. Another needle wasted.
This time, I do remember to properly dispose of my sharps and it's not just the facial reaction, it's the full-crying in the bathroom. I begin to suspect hormonal involvement. I allow a bit more time for the breathing, self-talk, and musical interventions this time. I splash some cold water and then head back to lab again.

epilogue: we had another TA come in to observe us for the final part of this lab, which was IM injections of each other. The TA and the woman I was working with both did the best thing in the world, which was look at me calmly, ask if she might do the injection on me first, and then ignore my tears. By that point, I was starting to be able to joke about it a bit, and recognize that being able to pull up saline into a syringe, while basic, may be something I need to do more than once in my life. I wonder if the fear of being stuck had an antagonistic affect as well, because by the time it was my turn, I was right as rain.

really here

So, I'm starting to feel like I'm in nursing school. I went to my second nursing student association meeting today, and beyond promising myself to expunge 'um' from my public speaking if I ever decide to run for an office in this organization, I was shocked to figure out that I've been here a month already!

I still have no clue what the prof in Fundamentals is talking about (nursing diagnoses all sound the same to me - and apparently there's some difference between 'as evidenced by neuromuscular weakness on left side' and 'related to inability to use left side of body', though it's certainly not obvious to me!), but the stuff she says is starting to sound familiar. I still don't get it, but I know she talks about it every class! I really feel like the first lecture in that class should be totally reworked - I didn't understand anything of what she said, and it was apparently really important, because I haven't understood her since then. Thankfully, I think I signed up to be on the advisory board for this class - maybe I can bring this up to her then. She is hands down one of my fav. profs!

My big news this week is that I passed my first skills eval - hand washing, sterile gloving, universal precautions with gown mask and gloves, and vital signs !!!! SHEW - what a relief to have that done and done well, according to the teaching assistant. There was a lot of contention among the students that didn't pass those skills the first time - they had to come back later this week and re-do specific skills - crazy stress and lots of folks felt like the variation of TA's was unfair. I don't know - it's not Scantron, and there are specific little checklists to follow... but I did see at least two instances of TA assholery that would have just done me in. Pa-Pow! Apoptosis! I felt lucky that the TA evaluating me was the TA who teaches my lab section - so easy. I think, though, that I will sign up for practice lab sections with some of the other, scarier TA's so that if I happen to get them in an eval, I won't freak out as badly.

My other big news is that I made an A a B+ on my first exam! It was more general than I was expecting, but it feels like I studied the right stuff and knew the kinds of things she asked. It was in Health Assessment, where we talk about what you expect to find in physical exams of patients, and what various findings might mean. We go from head to toe, and this class has a big evaluation at the end of the semester, where we do a head to toe assessment on someone (which apparently takes a couple hours!). We have labs to practice that examination, and this test was over the lecture portion of the class. this A makes me feel so confident that I'm doing what I should be to handle this material. I also have a little more confidence that I can handle this seven-point grading scale! A 92 is an A-, but it's still an A! (Right?!!! Isn't it!!????) oh well, maybe she'll throw out a question that I missed, like the one about what fungusy fingernails look like.

Nice to have two successes this week, since I've got two tests next week. Development, which will be nothin', and Patho, which is making more and more sense as I actually read the book.

So. my dishes are dirty, and my laundry is in mountains. But I'm happy, and feeling good. I'm eating well and remembering to bring my lunch to school most days. I went to the kid's school last week and taught his class to knit - wow! I'm still reading with a couple of kids at his school each week as a volunteer. I'm singing with a chorus led by a woman who used to teach music at the kid's preschool - she's super cool and full of quotes by Rumi and Hafiz about the present moment and releasing attachment to thought. And I'm going to a conference of officers of other Association of Student Nurses chapters this Saturday. The kid is good and super excited about his birthday next week! This birthday really seems like a departure from babyhood/toddlerhood.